Monkton Insurance Services Limited

Client Name:

Address:

Occupation:

Nationality:

Mailing Address: (If different from above)

Telephone Number:

Type of Insurance Licence Required:

Lines of Insurance to be Written:

Brief Description of the Business Plan:

Proposed Name of Captive (with two alternates):

Proposed Capital (US$):

Names, Addresses and Occupations of Beneficial Shareholders, and number of shares to be held:

Names, Addresses and Occupations of Proposed Directors:

Names, Addresses and Occupations of the following proposed officers:
Chairman President Secretary Any Other Officers

Name of Company's Bankers:

Name of Company's Auditors:

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